Note.

The total fee for submitting a paper Registration Form is listed on the PCAT Website and in the
CIB (the Registration Fee + the Paper Registration
Form Fee). Be sure to submit this form and your fee
payment so that they are received by Harcourt Assessment, Inc. by the Special Registration Deadline
appropriate for the PCAT test date.

Registration Form

Please provide all the information requested below by printing clearly or checking the appropriate boxes. Harcourt
must receive this form by the Special Registration Deadline. No late paper Registration Forms will be accepted.

Last Name

First Name

MI

Social Security/ Social Insurance Number

Birth Date: Month/ Day/ Year

Your Address: Street Number and Name

Apartment Number (or other address)

City

State/Province

ZIP/Postal Code

Country

Daytime Telephone Number

Email Address

Test Date
Preference
Please refer to the PCAT
website for upcoming
test dates

Test Center
Preference
Enter 3-digit code

1st 1 0 0 0
Doha- Qatar

Examination History
Have you taken the PCAT before?
(check one)
Yes
No
If you have taken the PCAT before, indicate the most recent test date:

2nd

Acknowledgement
I agree to adhere to all policies and procedures outlined in the current PCAT Candidate Information Booklet and on
the PCAT website and attest that the information provided by me on this form is true to the best of my knowledge.
I further certify that my own name and signature appear below on this form.

Signature

Todays Date: Month / Day/ Year

An application without a signature will not be processed.

Copyright 2007 by Harcourt Assessment, Inc. All rights reserved.

Page 1

Institutions or Organizations to Receive an Official Transcript

Code Numbers for 3 Reports Included in Test Fee:

Code Numbers for Additional Reports at an additional fee:

0199

If an institution or organization to which you would like to send an Official Transcript does not have a designated code,
email PSE Customer Relations at scoring.services@harcourt.com or call 1-800-622-3231.

Need for Special Arrangements

Information Release

If you need any special testing arrangementssuch as a Special Testing

Location, a Non-Saturday Test Administration, or a foreign test site
or if you need special accommodations because of a disability,
check here:

Schools of pharmacy may request your

name and address for recruitment purposes.
If you do not wish this information to be
released, check here:

Along with this form, be sure to include any required fee and all supporting
documentation as described in the CIB and on the PCAT website.

PCAT Fees

Payment

Fee for Submitting a Paper Registration Form . . . . .

See the PCAT Website

(Includes 3 Score Official Transcripts and 1 personal Score Report)

Additional Official Transcript Fee . . . . . . . . . . . . . . . . . . ______

Number of reports x Fee (See the PCAT Website)

Special Testing Location Fee . . . . . . . . . . . . . . . . . . . . . ______

(See the PCAT website)

Total Fee Payment Included . . . . . . . . . . . . . . . . . . . . . . ______

A money order for the Total Fee Payment

on the left must accompany this Registration
Form and must be made out to Harcourt
Assessment, Inc. Mail this form and your
payment to one of the addresses listed on
the PCAT website or on the inside front
cover of the current PCAT Candidate
Information Booklet.

Optional Information
By providing this information, you are consenting to its use for research and planning purposes only in
Harcourt Assessments ongoing efforts to improve the PCAT.

Sex

Ethnic Identification

(check one)

(check one)

Male
Female

American Indian or Alaska Native

None

Asian
Black or African American

Linguistic
Background
(check one)

English
Spanish
Other

Completed College Courses

Hispanic or Latino
Native Hawaiian or
Other Pacific Islander
White
Other

Less
Than
One
Year

One
Year

More
Than
One
Year

Biology
Chemistry

Current Educational Status (check one)

High School Student

CollegeThird Year

High School Graduate

CollegeFourth Year

CollegeFirst Year

College Graduate

CollegeSecond Year

Copyright 2007 by Harcourt Assessment, Inc. All rights reserved.

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